1. The Regulatory Process
The Role of Nurse Leaders *

2. Issues Confronting Nursing Leaders regarding Regulation
The Regulatory Burden on Nursing Care Hours
Lack of reimbursement for Regulatory activities
Staff understanding and education of the regulatory drivers of healthcare processes and procedures. *

3. Regulators of Hospitals Today
Centers for Medicare
and Medicaid Services
TJC

4. A Closer Look at Three Major Regulating Agencies
Centers for Medicare & Medicaid Services –part of the Department of Health and Human Services
Agency for Healthcare Administration
The Joint Commission *

5. Centers for Medicare & Medicaid Services
June 2002 Edition *

6. Centers for Medicare and Medicaid
In the past this agency was known as HCFA.
It is part of the Department of Health and Human Services.
Major areas of regulation include Medicare, Medicaid, SCHIP and HIPAA.
Initiator of the Core Measures now being used for Hospital Reimbursement *

7. Centers for Medicare and Medicaid
These quality measures are used to gauge how well an entity provides care.
Another quality measure introduced by CMS is the HCAHPS which is the patient’s perspective on care. This survey provides a comparison of patient satisfaction by facility and is posted on the Hospital Compare website for consumers to review.

8. Agency Responsibilities
Enforcement of all legislation related to these programs.
Investigation and surveys of facilities where violations are reported – example an EMTALA violation in an emergency room.
Provider payment for covered programs.
Development of policies on new programs such as HIPAA.
Providing the public information about quality issues with providers. *

9. Agency for Healthcare Administration*

10. Agency for Health Care Administration
Licenses and Regulates health care facilities and HMOs which operate in Florida
Responsible for the State Medicaid/Medicare Programs
Addresses consumer complaints regarding health care institutions.
Conducts State Surveys
Oversees the Certificate of Need for Health Care Services Program *

11. TJC – What is It? *

12. What is the Joint Commission?
An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

13. TJC
The decision to undergo TJC Survey is noted to be voluntary but is a requirement for healthcare facilities accepting Medicare and Medicaid payments as well as many state programs and those affiliated with colleges of medicine, nursing and other healthcare disciplines. *

14. Scope
Accredited 4365 hospitals in 2015; Total >20,000 organizations and programs
Types of hospitals general, psychiatric, children’s, rehabilitation
Others: Managed care networks, Preferred Provider Organization (PPOs), home care systems, long-term care, Subacute care, behavioral health facilities (mental health, mental retardation and chemical dependency), ambulatory care centers, clinical laboratories

15. Establish Standards & Requirements Related to:
APR
Environment of Care
Emergency Management
Human Resources
Infection Control
Information Management
Leadership
Life Safety
Medication Management
Medical Staff
NPSG
Nursing
Provision of Care
Performance Improvement
Record of Care
Rights
Transplant Safety
Waived Testing *

16. Process Used
Healthcare Agencies are surveyed against applicable standards for their mission.
Unannounced surveys are conducted approximately every three years but organizations are expected to be survey ready at all times.
TJC offers a computer based process where facilities evaluate themselves against the standards and subsequent onsite surveys confirm the information reported.
Patient Safety Goals are established each year and organizations are evaluated on compliance with these goals. *

17. Each Standard Consists of Three Parts: Standard Statement
Rationale and/or Notes (not in the excel file)
Elements of Performance (EP)
These are the score-able elements

18. FSA Scoring Sample

19. For Each Standard Ask yourself, ask your staff: Do we do this?
Where is it written we do this?
How well, or how often do we do this?
Show me the evidence that we do this
Validate the “doing” with high risk and high priority standards *

20. 5 Steps to doing the Right Thing Well : Sustained Execution=Continuous Readiness
Measure compliance or lack of...
Is it due to poor design?
Inadequate education?
Ineffective competency validation?
Variation due to work-arounds?
Variation due to unit, day of week, time of day, FT/PT/agency staff, etc.?
Management Intervention (appropriate action)
Manager
Measure compliance L I N E M A G R S
Manager
Validate competency
Staff dev.
Educate
PI team
Focus/PDSA/Rapid cycle design

21. Annual Internal Self-Assessment

22. Survey Process Opening Conference Leadership (High Reliability)
Medication Management
Infection Prevention Control
Data Management
Environment of Care
Emergency Management
Competency
Credentials

23. Accreditation Decisions
Full Accreditation
Accreditation with Recommendations
Provisional Accreditation – All Requirements for Improvement have not been addressed in the Evidence of Standards Compliance submission, or the organization has failed to achieve appropriate level of sustained compliance as determined by a Measure of Success result (when required).  *

24. Accreditation Decisions
Conditional Accreditation – Number of standards scored not compliant is between two and three standard deviations above the mean number of not compliant standards for organizations in that accreditation program.  The organization must undergo an on-site follow-up survey.

25. Accreditation Decisions
Preliminary Denial of Accreditation – Number of standards scored not compliant is three or more standard deviations above the mean number of not compliant standards for organizations in that accreditation program. There is justification to deny accreditation, but the decision is subject to appeal.

26. Accreditation Decisions
Denial of Accreditation – The organization has been denied accreditation, and all review and
appeal opportunities have been exhausted.

27. Resources – Nurse leaders need to read the Book and Newsletters – sample below is for hospitals

28. Most Common Areas Generating Deficiencies
Physical Environment
Surgical Services
Nursing
Governing Body

29. Units/Depts Receiving the Most Deficiencies
Operative/Invasive Areas
OR, Cath Lab, Radiology, Sterile Processing, Endo, Rehab, Anesthesia, Doctors Offices, ICU
Behavioral
Emergency Department
Provide Based Clinics
Cancer Centers

30. Nursing Issues of Current Concern
Nurse executive qualifications
Nurse executive oversight to all areas providing nursing care

31. Leadership Areas of Concern
Leadership responsibility and accountability
Contract management
Policies and procedures consistently implemented
Space
Disruptive behavior
Patient flow

32. Hot Topics with TJC Safety & Security Issues Medication Reconciliation
Timeouts
Patient Handoffs
Pain Management
Restraint & Seclusion
Staff Competency
Our Hot
Topics *